Chest pain triage in the ED: Is CT coronary angiography the answer?

Excerpt

The initial evaluation and triage of patients presenting to the emergency department with chest pain represents an enormous challenge. At one end of the spectrum, patients have non-cardiac diagnoses, including chest wall pain, gastroesophageal reflux, and peptic ulcer disease. At the other end of the spectrum, patients have definite acute coronary syndromes (ACS) with either ST elevation myocardial infarction or non-ST elevation myocardial infarction with positive cardiac biomarkers and ST segment changes. In between these two extremes, there are literally millions of patients who present to the emergency department each year with possible ACS. If their initial electrocardiogram and cardiac biomarkers are not diagnostic, how should they be managed? In the past, virtually all these patients were admitted to the hospital to “rule out myocardial infarction,” a conservative but expensive approach that ensured that the small percentage of patients who really had myocardial infarction were not incorrectly sent home. The first national Unstable Angina guideline, which was commissioned by the Agency for Health Care Policy Research in the early 1990s, pointed out that many of these patients were at low risk for myocardial infarction, and could be safely sent home without admission.1 However, many hospitals and physicians were uncomfortable with this judgment and developed a series of rapid evaluation protocols within the emergency department to identify patients who could be safely discharged. These protocols, which were published in a large number of observational and registry studies, were subsequently formalized as “chest pain centers” to reduce admissions and avoid unnecessary treatment. More than 550 hospitals in the United States currently have such centers, many of which are formally accredited by the Society of Chest Pain Centers. …